Two cases of distal extremity swelling with pitting oedema in psoriatic arthritis: the different pathological mechanisms

Abstract

In psoriatic arthritis, swelling and pitting oedema may be caused by diVerent pathogenic mechanisms: on one hand, the involvement of tenosynovial structures; on the other hand, the involvement of lymphatic vessels, which may be rarely implicated by the inXammatory process. This diVerent involvement is responsible for a diVerent response to therapy and a diVerent clinical outcome. In fact, patients with inXammation of the tenosynovial structures and normal lymphatic drainage have a more favourable clinical outcome and response to pharmacologic treatment, whilst patients aVected by psoriatic arthritis with chronic lymphatic vascular damage are characterized usually by resistance of oedema to therapy. In this study, we report two cases of psoriatic arthritis with distal extremity swelling and pitting oedema. In the Wrst patient, the swelling and pitting oedema were associated with lymphatic obstruction, as detected by lymphoscintigraphy. In the second, the predominant involvement of the tenosynovial structures, as shown by magnetic resonance, with normal lymphatic Xow, may have been the cause of arthritis with oedema. These diVerent pathogenetic mechanisms were associated with diVerent response to therapy. Nevertheless, oedema was resistant to therapy in both patients probably because of other unknown factors, which inXuence therapy and clinical outcome.

Bilateral Upper Extremity Edema in the Psoriatic Arthritis Case

“…The first mechanism is tenosynovial involvement, which has been reported only in a few cases. In the study of Quarta et al (6), the cause of edema was reported to be tenosynovial involvement in a case with normal lymph flow. Similarly, Salvarani et al (7) claimed that edema in their patient might have resulted from tenosynovial involvement.…”

Lower extremity swelling in a patient with psoriatic arthritis

“…Using lymphoscintigraphy and MRI, the researchers differentiated two distinct causes of extremity distention: i) tenosynovial inflammation and ii) lymphatic vessel dysfunction. 6 The authors suggested that patients with tenosynovial involvement without lymphatic changes had a more favorable outcome to teatment. In our patient, who showed no response to standard treatment options, lymphatic involvement may explain her poor outcome to therapy.…”

“…Both patients' arthritis symptoms benefited from treatment, but there was no improvement in lymphedema. 6 Lepka et al reported a patient with PsA and related left upper arm swelling who was successfully treated with etanercept therapy. 9 Our patient's lymphedema did not improve significantly after DMARD therapy.…”

Remitting seronegative symmetrical synovitis with pitting oedema (RS3PE) associated with psoriatic arthritis

“…According to our review of the literature, there have been two case reports of remitting distal extremity swelling with pitting oedema in PsA caused by tenosynovitis and one case with RS3PE as the first manifestation of psoriasis (4)(5)(6). Unlike the two case reports, we did not add oral corticosteroid to therapy of our case because of potential rebound of psoriasis.…”

“…Lymphoscintigraphy and magnetic resonance imaging (MRI) are useful in evaluation. RS3PE responds well whereas lymphoedema resists therapy (4,5).…”